04080235 CITY OF CUPERTINOBUILDING DIVISION PERMIT �sCONTRACTORI DRMATION -1
BUILDING ADDRESS: MASTER BUILDER & CONSTRACT ff'IND04080235
1045,5 RANDIEV MIR
OWNER'S NAME: PERMIT ISSUE DATE
E: SANRARY TO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMFFINFO
BLDGELECT PLUMB MECH
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LICENSED CONIRACfOR'SDECLARATION JbDi Description
C 1 MreM1y affiram liwve
m shot 1 d under provisios nof Chapter 9(com
mencinoescr
g P
b with Section 1")of Division 3ofdm Businexa and Professions Code.and my license is
in full derceap LIC # �•��t �5� TI--LEARNING CENTER
pqz Date e��_��_l++++++pppppp� S�����J��
o�,� Dam Contractor
ECL A101 aJrc Ua�
II- �", ARCNrtELTSDECLARATION�-
¢< 1 understand my plans shell be tied as public records
Dau P'We�7C..� Rt•.t...�C�,2_.
3
1Gt; Licensed Professional
OWNER-BUILDER DECLARATION
F I hereby affirm that 1 am exempt from N,Comrutor's License Law for the
O o following real(SCcOm 11D 1.5,Business and Professore Coda:Any city or county
%m which require a Permit to construct,alter,improve,demolish,or repair any structure
w�'^ prior to its issuance,also requires the applicant forsuch permit to file a signed smtement
��'< tMtW is liccned pursuanuo Nc pmvisimn of the Comracmr's License law(Chaper9 Sq. Ft. Floor Area �` Va
aim (aammcncingwiNs aonlaoa)ofDivfion3ofth BeimssandNor=iomCm&>or u
WNat he in exempt therefrom and the bmu for the alleged exemption.Any violation of ��}�{ v
Section]031.5 by any applicant for a permit subjects be applicantto a civil Penalty of 3 2 DLJ la�vs�jbgr0 0T e
not more than fw hundred dollars(S500). Y YP
❑1,uownerofthepmpart mmyemployuwithwagontheirretecompcnntlon,
will do N,work Code:
is Con isnotintendede offeredn not apply Loan Busmen
and ery,whoW Code:The contmcmh Ldwho law does not apply lf an owner of Required Inspections
Own employ, .ponvidds ed Oawsthimprowdwho am not intended
nsuch wmkhimselfm through his
ownver.do,building
pr suchimprovementsarcnot men dedmpleuedfmowner-
huilder Nebuilding brimprovementis soldwithinone year of compinifor be owe of
builder will haw the burden of proving Nm W did not Wild or improv for purpose of
sale.).
❑I,as owner of the propen,am exchedwly contracting with licensed conoamors to
construct be prejecl(Sec.70&L Business and Pmfesions Code:)The Council Li-
come taw does not apply to an owner of property who Wilds or improves theman,and
who concocts for such projects with a contncsar(s)licensed pursunuo Na Caroni
License law.
❑ I nn exempt under Sec .B&P C for this mason
Owner Dal
WORKER'S COMPENSATION DECLARATION
I lmmby afTosn under pemlty of perjury ane of the following daclmatione
Fare and will maintain a Certificem e
m of Consent self-insure for Workre
Worker's Compe
., ton,as provided for by Section 3700 of the labor Code,for be Performance of thc
work for which this permit is issued.
❑1 Mw and will maintain Worker's Compensation Insurance,as mquimd by Section
3700.17 be labor Code,fm Ne performanec of the work for which this pemut is issued.
My Workcts Compnuation Insmana Cartier mtd Policy number am:
coo b
Carrier:7(0i,p Policy No.:=h.
CERTIFICATE OF EXEMPOON FROM WORKERS'
COMPENSATION INSURANCE
('rhissection rued not M completed if the Permit is fm one hundred dollars($100)
or lras.)
1 cenify Nat in be Performance of the work for which this permit is issued.I shall not
employ any person in any mannerso as to become subject o the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making Nis Cenifica r of Exemption,you should
become subject to the Workers Campematim provisions of the labor Cruse,you must
.J O forthwith comply with such pmammm or his Pemail shall heaccusedrevo
ked.
Z CONSTRUCTION LENDING AGENCY
I hereby aRtm Nat them is a wmuex,inn lending agency,for be perfmmancer of
C the waft for which this permit u issued(Sec.3091.Ci,C.)
W QLender's Name
] Lender's Address
U Q I ecnify Nat I have mad Nis application and sunt,Nat be W.immenadur is
W F-' corl l agree to comply with all city and county ordinances and sore laws relating to
0 Wilding construction,and hereby authoritt rep¢enlaliws of Nis city to enter upon the
r� aWvc-Famumed Propeny for impcction purpose.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
F'y lobilide.judgmcn6,costs and expense which may in any way accrue against said City
U Z In consequence of the gmming of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION4.
`� -- Re-roofs
Signal o ApplicanU mucor o. '
H ARGODataS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant in.or handle harardou material
az&fined by the Cu p,mirm Municipal Code.Chapter 9.12,and Ne Heald and Safety
Code,Sermon 25532(x)1 All roofs shall be inspected prior to an roofing material beim Installed.
❑Yea rfl No P P Y g g
Will the applicant or future building occupant use equipment or&vices which If a roof is installed without first obtaining an inspection,I agree to remove
I haralloo air contaminants re&Oneus by be Bay Area Air Quality Management all new materials for inspection.
vicR
U ye, �tNu
1 have mial be hanrdmorrawrials requirements un&r Chaperb.95 of the Cab or.
ria Health&SafetyCode.Sectiau25505,25533 not 2 53x.1 understand Nviftbe Wilding
dote not cowed,haw•he ant t it is my mspomibiloy in ready the occupant of the
Mquiremenuwmchmast ren rwissrream.fecertificieof0murpsicy. Signature of Applicant Date
Owncf or authoriccd agcot Dae All roof coverings to be Class "B"or better